Robotic surgery has transformed laparoscopic surgical treatments. More and much more centers across the World are purchasing robotic devices for surgery. While the first cost might be substantial, marketing campaign results and improved outcomes towards the patient are worth the investment. Robotic devices offer the surgeon unprecedented control and precision from the surgical instruments employed during minimally invasive procedures. This leads to less postoperative pain for that patient, shorter hospital stays, quicker recovery times, better cosmetic effects, and physiologic function. In most cases, one may initially make a robotic device inside a sci-fi or futuristic reference, being autonomous and replacing the human surgeon. This couldn't be far away from the truth. Robotics, while an indication of the days and also the future, require human intervention to operate. They help surgeons - not replace them.

Historical perspective

Robots were initially designed by the nation's Aeronautics and Space Administration (NASA) to be used in space travel. These robotic devices were used in performing manual tasks aboard a spacecraft or in space where a human couldn't go or, a minimum of, movement will be limited. Known as “slave devices”, they were controlled from a remote master control on Earth or from another spacecraft and were utilised extensively aboard the area Shuttle missions between 1983 and 1997. From that technology emerged “virtual reality” which allowed the interaction with three-dimensional virtual screens. Robotic engineering and virtual reality were then coupled together to develop a dexterous telemanipulator for the anastomoses of nerves and vessels in hand surgery.

The U.S. Department of Defense recognized the applications that robotics and virtual reality could provide in treating wartime casualties on the battlefield. Through the application of virtual reality, a wounded soldier could “be brought” to some surgeon. This became referred to as “telepresence.” Via this concept, a surgeon located on board an aircraft carrier could perform surgical interventions on a wounded soldier who remained inside a remote location close to the battlefield. As a result, the Department of Defense went on to finance much research utilizing telemanipulation coupled with telepresence to be used in mobile surgical units. To be able to incorporate fraxel treatments to its full potential, engineers remarked that the distance between your patient and also the surgeon had limitations. To make sure the best accuracy and dexterity of the robotic device, the transmission delay or lag time between the surgeon’s maneuvers and also the robot’s reception of the commands and implementation required specific design. Delays exceeding 200 milliseconds would compromise the surgical accuracy and precision. Subsequently, the employment of high-bandwidth fiberoptic underground cable over long distances is discovered to be the very best solution in those days, permitting a latency time of 155 milliseconds.

The first video-laparoscopic cholecystectomy was performed later in France. In 1988, the innovation of laparoscopic surgery was brought to the Society of American Gastrointestinal Endoscopic Surgeons. From that time on, the implementation of laparoscopy exploded! The advantages were soon realized: less invasive with better patient outcomes. On the flipside, it was virtually a brand new surgical realm to master. Surgeons lost their three-dimensional vision and impaired touch sensation. Additionally, a surgeon had to learn how to manipulate long instruments inside the patient’s body that were not directly being viewed. While advancements were made in regards towards the logistics and the surgical instruments of laparoscopy, a much better technique was coming. Hence, the incentive for robotic development. The ultimate goal ended up being to create a master-slave manipulator device which may mimic the natural movements of a surgeon’s hand and wrist. Early designs contained 4 examples of freedom by 1992, a musical instrument was developed that allowed for 6 examples of movement. In 1999, Intuitive Surgical acquired the rights for the existing technology, utilizing this to build up robotic instruments with 6 degrees of freedom that have evolved to what has been popular today.

da Vinci Robotic Surgical System

One of the most modern surgical robotic systems approved by the FDA - the da Vinci. This is really a telemanipulator robot which means that it is under constant control of the surgeon operator who sits inside a remote console. It is comprised of 3 components: a console, an optical three-dimensional vision tower, along with a surgical cart. The surgical cart (the robotic component) consists of 3 arms that are manipulated by the surgeon via “real time” computer assisted control. One arm supports the endoscopic camera and the other 2 hold surgical manipulators and instruments. The latter employs 6 degrees of freedom plus grasp, equilibrating it towards the articulation of the surgeon’s hand and wrist. This is an extremely heavy piece of equipment and extreme care should be taken with moving it. After the individual lies for the surgical treatment, the cart must be rolled to the surgical area and it is then locked into position. It is imperative that the patient’s position isn't changed after the robotic side arm is “docked” to avoid injury to patient. The console allows for a three-dimensional picture of the surgical field. The endoscope transmits two separate optical and digital images towards the console’s visual monitor. The surgeon is visualizing two separate monitors, each eye seeing through an independent camera channel which creates a three-dimensional image of the surgical field. Within the console, there are 2 levers - “the masters”, which affix to the surgeon’s index fingers and thumbs. There will also be 3 foot pedals which allow the surgeon to disengage the robotic motions, adjust the endoscopic camera, and control the cauterization. Lastly, the optical tower includes computer equipment which coordinates the left and the right “eyes” from the surgeon providing stereotactic vision. The computer also translates the movement of the surgeon’s hands into a gifs that corresponds to the robot’s articulations.

Surgical applications

Robotic technology has been successfully implemented in many surgical treatments, including gastrointestinal laparoscopic surgery, cardiac surgery, thoracic surgery, neurosurgery, urologic surgery, orthopedic procedures, and gynecologic procedures. I am the most familiar with robotic assisted urologic and gynecologic procedures to ensure that is exactly what I will specifically highlight. If robotics is being utilized in other types of surgical treatments listed above in which you practice.

Urologic surgery

In the University of North Carolina at Chapel Hill, the urology surgeons are fantastic using the da Vinci. Some of the primary urologic surgical treatments that employ the da Vinci robot are:

1. nephrectomy,
2. pyeloplasty,
3. cystectomy with ileal conduit, and
4. radical prostatectomy.

The second has become the most frequent procedure which utilizes the da Vinci robot. Prostate cancer may be the leading type of cancer in males. It may be the second highest reason for death in males in america, killing a lot more than 40,000 men annually. Early detection carries the very best prognosis and allows patients to have more treatments, including surgical removal from the prostate. In a nutshell, the goals surrounding a radical prostatectomy are:

1. Remove the prostate and cancer
2. Preserve urinary function
3. Preserve erection health (via a nerve-sparing procedure or approach)
4. Analyze the prostate after surgery to evaluate the risk of recurrence of cancer

As outlined above, performing a robotic assisted laparoscopic radical prostatectomy provides the surgeon AND the patient several benefits. The da Vinci system allows the surgeon to have enhanced magnification, a 3-dimensional view of the operative field, and preserve the nerves accountable for erections.

The individual benefits greatly too:

1. Decreased blood loss
2. Shortened period of hospital stay
3. Decreased postoperative pain
4. Less scarring
5. Shorter urinary catheter time
6. Faster return to regular activities
7. Anticipation of improved potency and continence
   

Gynecologic surgery

Robotic assist may also be widely used in gynecologic procedures for various underlying disorders: fibroids, pelvic masses, abnormal bleeding, endometriosis, pelvic floor disorders, and precancerous/cancerous disease processes. Depending upon the problem, treatments might not necessarily include surgery. On the flipside, hysterectomy is easily the most common surgical procedure performed in women and roughly numbers about 650,000 cases annually in america. The primary reason is the fact that it is the definitive solution for many types of common gynecologic conditions. If surgery is indicated, minimally invasive surgical (MIS) procedures have numerous advantages that are quite similar to those outlined earlier:

1. Minimal hemorrhaging
2. Preservation of love and fertility for fibroid removal/myomectomy
3. Decrease in a hospital stay
4. Less postoperative pain
5. Absence of a midline abdominal incision
6. Quicker recovery time

Anesthetic considerations in Robotic Surgery

Several of the anesthetic implications specific to robotic procedures mimic those for any laparoscopic surgery. However, there are several considerations unique to those procedures that anesthesia providers have to appreciate and understand. Some of those are surgeon preferences but nonetheless, have good rationale in it because they result in optimal surgical conditions as well as in the long run, better outcomes for that patient. So, let’s highlight a number of the main considerations.

Anesthetic technique and agents

For any from the robotic procedures mentioned above specific to urology and gynecology (my experience), these patients always get a general anesthetic. A regional block - i.e. epidural catheter placement, either for anesthesia supplementation and/or postoperative analgesia is not really indicated or even necessary. Every anaesthetist has a common anesthetic drugs, inhaled anesthetics, and techniques that we like to employ. As with any patient having any surgical treatment, the chosen anesthetics should be catered around the patient, the patient’s history, and their accompanying co-morbidities. Many surgeons avoid the use of nitrous oxide with laparoscopic procedures for several reasons. Postoperative nausea and vomiting includes a higher incidence. So, why create a potentially bad problem worse? Additionally, high narcotic loads are not generally required as postoperative pain far less a problem.

Placement of IVs and extra invasive lines

For robotic assisted laparoscopic procedures, the patient’s arms will be tucked in/secured at the sides. Additionally, you won't be able to access the patient’s arms or look into the patency from the IV or fiddle using the noninvasive blood pressure level cuff when the robot is “docked” into position. There are some causes of the latter. Not only may be the robot a huge piece of equipment but it will be literally in the way of accessing the individual. Also, the whole area above the patient is recognized as sterile. Place anything in the patient (additional IVs, an arterial line) PRIOR to the robot being positioned and locked into place above the patient. It is advisable to place a second large bore peripheral IV after induction. The patient usually may have were built with a bowel prep, probably will be dehydrated, and the surgeons will work in close proximity to large blood vessels. In the event you have to give volume and/or blood products quickly, you can do so without trouble if your second large IV is in place. And make use of a fluid warmer with the second IV set up. An anesthesia colleague once told me that he never needed to dc an IV STAT. Makes sense…the second IV can always be removed easily when the patient reaches the PACU. Once again, you will not have the ability to crawl up underneath the drapes and begin another IV very easily within an emergent situation. Arterial line...placing one or not placing one should be determined by the individual and the patient’s presenting history. As along with other clinical scenarios and patients, quite often we place an arterial line for “our convenience.” Because the patient’s arms are tucked, through an arterial line for the sampling of ABG’s, a hemoglobin level, or perhaps a blood sugar levels can be invaluable. If the individual does not warrant an arterial line postoperatively, it is simple for that PACU nurse to get rid of after that it. Guarantee the IVs run well following the arms happen to be tucked in and also the arterial line comes with an acceptable waveform.

Positioning the patient

The individual is under general anesthesia, the needed lines are in position, and now the surgeons will be ready to go! It is very important that all personnel within the operating room take an active role in properly positioning ANY patient for that surgical treatment. However, with robotic assisted procedures, there are a few nuances. Also, a surgeon might have a particular positioning technique or strategy which is fine as long as it’s safe for the patient. Since my primary experience is by using urology and gynecology procedures, it is exactly what I will discuss. For probably the most part, both require similar positioning of the patient.

Robot assisted laparoscopic prostatectomy

Arms padded and tucked at sides and well secured. Place a beanbag high in OR table using the U shaped tops wrapping round the patient’s shoulders for stabilization. Blue foam donuts will also be placed between the shoulder AC joints and beanbag for padding. Padded shoulder blocks are then placed behind the beanbag for added stabilization to prevent the individual sliding within the cephalad direction when placed into steep Trendelenburg. Towels are placed over the patients chest and then wide adhesive tape is crossed across the patient’s chest and shoulders within an X formation to secure the individual to the OR table. Surgeons make use of a special OR table which splits the legs for surgical positioning. This minimizes the risk of peroneal nerve injury. Once all of that is done, a “testing” from the Trendelenburg position is conducted to ascertain that the patient is safe on the OR table and does not slide down within the cephalad direction. This is essential since the patient come in steep Trendelenburg for quite some time.

Robot assisted pyeloplasty

Lateral position - kind of a tilt, using the operative site on the body (i.e. right or left) being up and also the patient can remain relatively flat. A beanbag is used to secure the patient. Don’t your investment axillary roll. Proper padding should be present between the arms and the legs, especially between bony prominences. Ensure that the “up arm” is well secured therefore it doesn't fall and stretch any nerves. Make sure the male genitalia aren't getting squished between the bean bag and the body.

Robot assisted gynecologic procedures

Arms padded and tucked at sides and well secured. While supine, padded shoulder blocks are placed better than the AC joints and fit snug about the OR table. The patient’s legs are placed into padded leg holders and gently bent at the knee. Steep Trendelenburg can also be required for this patient.

Nerve injuries remain one of the most common adverse outcomes in surgical patients and reported closed claims event. And while a patient may sustain a nerve injury even with probably the most meticulous surgical positioning and precautions placed, most nerve injuries are preventable. That implies that we have to understand proper surgical positioning techniques, have the proper surgical padding and positioning equipment to utilize, and be aware of nerves which are at greatest risk for injury with this patient as well as for this process. The ulnar nerve is the most common nerve injured during surgical treatments and anesthesia. One reason behind its vulnerability is its superficial mislead the skin surface. It may also be easily trapped between your bony prominences surrounding it. Ulnar nerve injury is slightly less prevalent once the arms are tucked in the side. However, it remains important to wrap gel pads or foam around the ulnar area. The fingers and hands should also be properly padded and secured. With gynecological surgery, the foot of the bed will be lowered. Ensure the fingers aren't wedged in-between the OR table and also the moveable end on the table foot piece. If they're, it is a fantastic way to crunch fingers. Additionally, cut off the clamps about the IV tubing that will be alongside the patient’s skin. Also, place a 4x4 between any IV connections and/or stopcocks to ensure that these do not place pressure or leave an indentation within the skin. Once the arms are secured, make sure that the arms are actually secured. With draping and positioning, it might be more difficult to detect when the arms “slipped” and therefore are now dangling along side of the OR table.

When the legs are placed into padded leg holders, make sure that the legs are symmetrical - one shouldn't be greater than the other. Also, excessive flexion and extension should be avoided because this can stretch the sciatic nerve. Ideally, the lower limb ought to be inside a relaxed mid-position and both sides of the knees padded. The peroneal nerve runs lateral to the knee and the sapphenous nerve runs medial to the knee. If there is excessive pressure either to of those areas, these nerves are at jeopardy for injury. If padded shoulder blocks are used (as stated before), astute and frequent checks for excessive pressure over the AC joint are mandated, especially when the patient is placed to the steep Trendelenburg position. Excessive pressure about this the main shoulder may cause brachial plexus injury. Keep in mind that when the blocks are placed better than the shoulder while the patient is in the supine position, they might not feel “tight” above the shoulder. But when the patient’s head is lowered and gravity forces the body weight downward, the second force is going to be exerted from the shoulder blocks. Therefore, it is advisable to check the positioning from the blocks once they are put into place and make sure they fit very loosely round the shoulder - 2 fingers can easily be wedged between the shoulder and the block. This is sort of of the insurance plan to ensure that when the patient goes head down, at least the blocks were not too tight to start with.

Positive pressure ventilation - the difficulties and the solutions:

Most Anaesthetist have administered anesthesia for patients undergoing various laparoscopic procedures and are conscious of the potential pulmonary dynamic changes that occur secondary towards the CO2 insufflation. While this is true for robotic assisted laparoscopy, it is worth mentioning a few words concerning the steep head-down position which is required. The combination of the positioning and CO2 insufflation could make ventilating these patients challenging. If the individual is obese, it might be much more challenging. Utilizing pressure ventilation can nicely circumvent this problem and permit us to achieve adequate tidal volumes. Keep in your mind that you need to be watchful from the peak aspiratory pressures and not allow them to become excessive. The placement of an oral gastric tube is warranted.

IV fluids should be minimize!

Because patients have been NPO and especially should they have undergone a bowel prep, we are inclined to want to give our patients a lot of IV fluids, especially at the beginning of the situation. When you're providing anesthesia for any robotic assisted urologic or gynecologic procedure, forget about that concept! The exception is perfect for pyeloplasties. Genarally surgeons request that fluids intentionally be minimized before and during the surgical procedure. The primary reason for this is that excessive IV fluids potentiate the formation of edema in the face as well as in the airway mucosa quite possible preventing extubation of the patient. When these cases were taking longer to perform, this was an extremely real encountered problem. In robotic prostatectomies, minimizing the IV fluids may also keep excessive urine out of the pelvis which could obscure the surgeons’ view while sewing the anastomses. At the end of the case once the patient is flattened out, the surgeons then approve for us to give the patient IV fluids when needed. In robotic prostatectomies, our surgeons actually ask us to start loading the individual with IV fluids at the moment point. Preoperatively, I like to inform the patient and any family members that it is not unusual in order for there to be visible swelling within the patient’s face and eyes postoperatively due to the steep head down position. While this can normalize within the first few hours following the procedure is complete, it may be a bit alarming to see and experience, particularly if it weren't discussed ahead of time.